balloon covered distal opening with temp probe, placed IN DISTAL 1/3 of esophagus in ANESTHETIZED patients…excellent quality of breath and heart sounds, accurate core body temp

CO2 level with MH:

high

CO2 level with hypothermia:

low

CO2 level with embolism:

low

clinical application of capnometry: 5

metabolism (MH, hypothermia) circulation (CPR adequacy, embolism) respiration (apnea, hyper/hypo ventilation, confirm ETT) breathing system (absorbent, unidirectional valves) correlation with PaCO2 (1-6mmHg range- not if dead space or VQ mismatch)

EtCo2 correlation with PaCO2: range and 2 factors causing poor correlation:

1-6mm Hg, dead space and VQ mismatch

Phase I of capnography: select 3

corresponds to dead space ventilation, CO2 should be zero unless rebreathing occurs, fresh gas moves over the sampling site

Phase II of capnography: select 2

early exhalation/ steep upstroke, quick mixing of dead space with alveolar gas

Phase III of capnography: select 3

horizontal with mild upslope, CO2 rush alveolar air, represents maximum CO2 at end of phase

Phase IV of capnography: select 2

inspiration phase, pure fresh gas

what phase of capnography would be evident of CO2 absorbent exhaustion:

what phase of capnography would be evident of incompetent expiratory/inspiratory valves:

what phase of capnography would be evident of Bain circuit flows too low:

prolonged (less steep) upstroke of phase II would indicate: select 3

mechanical obstruction, COPD, bronchospasm

prolonged (less steep) downstroke of phase IV would indicate:

restrictive lung disease

Steepness of Phase III might indicate: select 3:

COPD, bronchospasm, right mainstem

dead space ventilation

P-Q=

mixed alveolar dead space ventilation

Q-R=

alveolar ventilation

R =

max CO2

R-S=

inhalation (pure fresh gas)

true regarding this photo:

prolong upstroke of phase II, obstructive disease, COPD/asthma, bronchospasm

true regarding this photo:

CO2 absorbent exhausted, EtCO2 does not return to baseline 0

true regarding this photo:

decrease in CO = ? the height of capnogram

decrease

CO2 absorbent exhausted will cause a _______ rise in EtCO2?

gradual

2 things:

curare cleft: sticking of inspiratory valve or spontaneous breathing on vent

phase III steepness =

expiratory resistance

loss of plateau might indicate:

COPD, asthma, bronchospasm, mechanical obstruction

5 standards for oxygenation

continuous pulse ox with variable pitch tone continuous auscultation continuous clinical observance O2 analyzer and low O2 concentration alarm disconnect alarm on vent

02 analyzer location and what it does

inspiratory limb of circuit and measures fiO2

deoxygenated hemoglobin absorbs:

visible red at 660

oxygenated hemoglobin absorbs:

infrared at 940

beer lamberts law:

relates intensity of light through a substance, blood, and concentration of dissolved solute, hemoglobin

factors affecting pulse ox accuracy:

ambient light, patient movement, shiver, hypothermia, low CO, dyshemoglobinemias: methemoglobin (falsely low) and carboxyhemoglobin (false high), injected dyes

what does carboxyhemoglobin do to pulse ox:

absorbs light identical to oxyhemoglobin and will give falsely high reading pulse ox

factors with no effect on pulse ox:

bilirubin, HbF, HbS, flourescein dye, acrylic nails

o2 saturation is directly proportional to:

the amount of oxygen dissolved in the plasma

PaO2 of 30 = SaO2 of

PaO2 of 40 = SaO2 of

PaO2 of 60 = SaO2 of

regarding the oxy hemoglobin curve, large % change of saturation occurs at PaO2 of _____ and SaO2 of ______.

60 90

5 circulation standards

1. BP/HR q5min 2. continuous ekg 3. continuous pulse ox 4. continuous auscultation 5. digital palpitation

3 limb ekg: largest voltage projection on lead ?

3 electrode system EKG, which lead is best to detect p waves and NSR

which single lead best detects ischemia:

which lead combo is best for detecting ischemia:

II and V5

what 3 leads are 98% sensitive to detecting ischemia:

II, V4, V5

3 detections of lead II:

yields max p wave, detect dyshythmias, detect inferior wall/ST depression

V5 (brown lead) benefit and location

5ICS/ left anterior axillay line…detect anterior and lateral wall ischemia

detects anterior and lateral wall ischemia

detects inferior wall/ ST depression:

NIBP disadvantages: 6

leaning on cuff, shiver, motion, site limitation, trauma, not continuous

why is radial artery most commonly used for a lines:

dual blood supply

AANA standard for body temperature:

continuous for all peds general anesthesia and as indicated for everyone else

temperature of hypothermia

< 36 C

temperature of significant morbidity:

< 34C

temperature of fibrillatory:

< 32 C

how much temp can body lose per hour?

0.5-1 C

core temperature prob locations:

pulmonary artery, distal esophagus, tympanic membrane, nasopharyngeal

liquid crystal temperature monitoring:

Mylar strips of liquid crystals, temp variations change molecular arrangement, reflects temp accordingly

advantage of liquid crystal temp monitoring:

cheap, easy to apply, noninvasive, safe, useful for regional/MAC cases

disadvantages to liquid crystal temp monitoring:

inaccurate, varies with application site, does not approximate core body temp directly

tympanic temperature reflects what temp?

brain

disadvantages to tympanic temp:

potential for membrane perforation

disadvantage to rectal temp:

slow response to change in core body temp

offers best combination of cost, performance and safety in regards to temperature monitoring:

esophageal probe

esophageal probe:

best combo of cost, performance and safety placed in lower (distal) 1/3 of esophagus accurate core body temp

standard for neuromuscular function:

continuous monitoring when blocking agents are used TOF documentation frequency is agent specific

how often to chart TOF:

frequency is agent specific

features of nerve stimulator:

maintain current for duration of impulse battery power charge indicator low battery alarm high output/low output sockets audible signal with each stimulus mult patterns of stimulation

the response of the nerve to electric stimulation of TOF depend on 3 factors:

current appplied duration of current position of electrodes

TOF stimulation patterns: 5

single twitch TOF double burst titanic post titanic count

when single twitch stimulation is used:

used to time onset of neuromuscular block in prep for Tracheal intubation

single twitch stimulus:

supramaximal stiulus frequency 0.1- 1Hz for 0.2 msec 7-10 seconds- says on her slide

TOF stimulation:

4 separate supramaximal stimulus 0.5 sec at 2 Hz for 2 seconds

used to time onset of neauromuscular block in prep for tracheal intubation:

single twitch

TOF ratio:

evaluate fade and compare T4: T1 ratio divide amplitude of 4th response by 1st response inversely proportional to the degree of block

4 twitches =

less than/ equal to 70% blocked

3 twitches =

75% blocked

2 twitches =

80% blocked

1 twitch =

90% blocked

0 twitches =

95% blocked

double burst stimulation: 4

2 tetanic stimuli at 50 Hz with 0.75 sec pause response to each burst is perceived as a single muscle contraction more accurate in determining fade does not exclude residual NM blockade

most accurate in determining fade:

double burst

FADE:

NDMR act on prejunctional cholinergic R as part of a positive feedback mechanism controlling Ach mobilization blockade of these interferes with mobilization and produces fade stimuli of post junctional R opens the ion channels and allows the drug to enter the channel producing an open channel block

Tetanic Stimulation:

rapid delivery of stimuli- sustain muscle tetanus without fade 50 Hz for 5 seconds 50% of receptors can still be occupied assess residual muscle relaxant if contraction is held for 5 seconds without fade then significant paralysis is unlikely precense of fade: >75% of receptors are blocked no fade = correlates with the ability to protect airway after intubation

used to assess residual muscle relaxant:

tetanic

ulnar nerve monitoring: contraction of what muscle:

adductor policis

preferred nerve to stimulate to determine NM blockade

ulnar

nerve in face to stimulate

orbicularis oculi

most resistant to NM blockers:

diaphragm

highly resistant to NM blockers:

laryngeal adductors

resistant to NM blockers:

orbicularis oculi

100

sensitive to NM blockers:

abdominal rectus